"Assessment" versus "Diagnosis": what are the differences?

[Veneficus]

Might as well lock this thread up too.

 

[LondonMedic]

Sssssh, don't tell Novia Scotia or Alberta who are doing field cardiac enzymes

Are they holding the pt in the back of the ambo for twelve hours?!

I know travel times can be long, but seriously...

 

[VentMedic]

Are they holding the pt in the back of the ambo for twelve hours?!

I know travel times can be long, but seriously...

Why would you hold a patient for 12 hours?

POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.

 

[LondonMedic]

Why would you hold a patient for 12 hours?

POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.

I know, I use these machines regularly, they are both a blessing and the bane of my life.

The key question questions here; what is the significance of an immediate troponin?

Do you not do serial (6hr and 12hr) trops? Immediate trops are usually -ve and often misleading. Even +ve trops are often misinterpreted.

 

[VentMedic]

I know, I use these machines regularly, they are both a blessing and the bane of my life.

The key question questions here; what is the significance of an immediate troponin?

Do you not do serial (6hr and 12hr) trops? Immediate trops are usually -ve and often misleading. Even +ve trops are often misinterpreted.

Let me repeat my post:

POC testing can generally give a troponin (protein) level in about 15 minutes. It can at least be used to determine destination if travel distance is great or used to initiate treatment based on clinical assessment and a 12-Lead ECG.

If we have a positive tropinin on a symptomatic patient, we may still transport to a facility that has a cath lab regardless of the ECG since an ECG can be nonspecific. Waiting 24 hours for ECG changes might cost heart muscle. Remember, no one should ever rely on just one test and clinical correlation is a necessity.

While one would more than likely transport to a cath lab center, that may not always be the case depending on local protocols. As well, if you have a LONG transport time, there is a good chance the cath lab team members may have a long drive time when activated if not in house 24/7.

But, these machines are not on all EMS trucks and are generally reserved for a few Flight, CCT and Specialty transport teams.

 

[mycrofft]

"Diagnosis" versus "assessment" boils back to transport time versus benefit?

It seems to me then , by looking at the poll, that we can provisionally agree that for all intents and purposes field EMS does "diagnose" , if not by that name. Then the depth and quality is affected by practice limits/protocols and practicality (time factor from scene to hospital).

 

[dave3189]

Dictionary defintion

Diagnose: to determine the identity of (a disease, illness, etc.) by a medical examination. to ascertain the cause or nature of (a disorder, malfunction, problem, etc.) from the symptoms

I can't believe we are still having this age old discussion? I always find that the nay sayers of this debate are often the medics that are worried about protecting their "turf". Bottom line, to diagnose something does not mean it is a complicated procedure that requires an advanced and/or invasive protocol?

As an EMT-B, how can it be logically or rationally deemed "not a diagnosis" when I arrive at a scene and see an 8 year old child in respiratory distress, with a peanut butter cookie sitting next to her with Mom saying she is allergic to peanuts. BP shows her hypotensive, she has red/rashy skin. Hmmm, my medical assessment along with a history points to Anaphylaxis treated with Sub Q Epi and an ALS response. Remind me again how that isn't a diagnosis???

How about a more simple example... I arrive at a call of a teenager who wiped out on his skateboard. Upon assessment I see an open Tib fracture. Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals. Again, while a very simple call... I diagnosed this patient with an open fracture. What is so difficult to comprehend about this topic?

 

[JPINFV]

How about a more simple example... I arrive at a call of a teenager who wiped out on his skateboard. Upon assessment I see an open Tib fracture. Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals. Again, while a very simple call... I diagnosed this patient with an open fracture. What is so difficult to comprehend about this topic?

Nope... sorry... that's just a painful swollen deformity.

 

[dave3189]

My bad, I should have requested a Medic Unit to "diagnose" my "observation".

 

[VentMedic]

So a sign and a symptom is essentially a diagnosis?

How many causes of CHF? Is it a sign, symptom or a disease or all? Can you make the diagnosis of acute renal failure as the cause or diagnosis?

What about wheezing? COPD or Asthma? What about all the other causes or disease processes? Do you treat the signs and symptoms or do you immediately go straight with asthma? What if it is an aspirated object? Does that change the diagnosis of the wheezing?

How much is "assumption"? Look in the scenarios heading for examples of the "guessing game" where some assume but really don't have much data to go on.

What about the commonly made diagnosis of "hyperventilation"? Isn't it really a symptom called tachypnea since there is not clinical data to prove hyperventilation?

What if you do a glucose check on a trauma patient and find a higher BGL? Are you going to assume the patient is a diabetic?

Protocol is for me to control bleeding, dress & splint and transport with 02 while monitoring vitals.

For the fx, if you have diagnosed it, why O2? Aren't you just following your protocols instead of actually clinical findings of hypoxia? Are you also going to stop your assessment since it is so "obvious"? Any chance of emboli?

And, for the respiratory distress, are you going to stop your assessment after giving the SQ? Since the child was eating, is aspiration and obstruction also not a possibility as well? Rarely are things always as easy as they seem and to ASSUME one thing you may miss another.

Yes, you must work under a preliminary diagnosis to initiate your protocols but one should also not stop assessing or believe that one diagnosis is the end all to every problem.

Let's do another scenario since pericarditis was just mentioned in anther thread. How about the "typical" OD patient with a history of IVDA. The narcan barely touches him. Do you suspect endocardititis which can lead to a CVA and/or MI? Or do you stick with the obvious of OD and keep giving narcan to the limit allowed by your protocol? Can an unconscious patient tell you about chest pain or slurred speech? So no, not everything will be a simple textbook diagnosis and treatment symptoms or signs as you find them will be all you can do. Just assuming you made "a diagnosis" and running with that may not provide all the treatment that can be done.

If you have ever shadowed the ED physician, you will find they may list as many as 6 or more differential diagnoses even with something that seems really obvious and will continue to treat the signs and symptoms as they appear until some definitive data is available.

This is to get some to thing there is more than just the obvious and rarely will a patient have just one diagnosis but can have many signs and symptoms that can pertain to many disease processes each with a different definitive treatment but similar treatment of the signs and symptoms.

 

[dave3189]

Where does it indicate that a "diagnosis" has to reach some specific, (and yet unmeasurable) level of advanced diagnostic/clinical medicine to be considered such?

According to your contention, an attending at the ED who treats an elderly woman from a fall who scans her and finds a hip fracture isn't diagnosing her? How does he know that she doesn't have osteoporosis? According to your theory, the Doc is just treating the symptoms of the disease? What you fail to realize is there is always another layer of diagnostic speciality that a patient can be referred to.

I had a laminectomy when I was a kid for a herniated disc. It was caused by a staff infection that reached the lumbar area of my back. I guess the orthopedist who examined me, interpreted the films and performed the surgery didn't diagnose me? I suppose he was really only treating the back symptoms which were secondary to the infection. I was examined and treated by a pathologist who treated the infection, so he must have been the one to have ultimately diagnosed me.

That is how silly this argument is! There is no question that there are simple basic levels of diagnosis and there is an advanced level of diagnosis... however when you use signs, symptoms, patient history and a physical assessment to determine an appropriate level of care it is ludicrous to claim it is not a diagnosis!

 

[VentMedic]

Where does it indicate that a "diagnosis" has to reach some specific, (and yet unmeasurable) level of advanced diagnostic/clinical medicine to be considered such?

According to your contention, an attending at the ED who treats an elderly woman from a fall who scans her and finds a hip fracture isn't diagnosing her? How does he know that she doesn't have osteoporosis? According to your theory, the Doc is just treating the symptoms of the disease? What you fail to realize is there is always another layer of diagnostic speciality that a patient can be referred to.

I had a laminectomy when I was a kid for a herniated disc. It was caused by a staff infection that reached the lumbar area of my back. I guess the orthopedist who examined me, interpreted the films and performed the surgery didn't diagnose me? I suppose he was really only treating the back symptoms which were secondary to the infection. I was examined and treated by a pathologist who treated the infection, so he must have been the one to have ultimately diagnosed me.

That is how silly this argument is! There is no question that there are simple basic levels of diagnosis and there is an advanced level of diagnosis... however when you use signs, symptoms, patient history and a physical assessment to determine an appropriate level of care it is ludicrous to claim it is not a diagnosis!

Do you think any of these doctors were looking for only one diagnoses bases soley on the obvious? If you had read my previous post you would have noticed my comment about an ED have several different diagnoses to work from and does not pigeon-hole him/herself into one.

Do you know how differently a CCT, Flight or Specialty team might treat the same patient brought to the ED by EMS based on a couple of lab values? What about the obvious OD? Do you think a CT Scan finding of a CVA might change the "OD" diagnosis or at least add to it?

 

[dave3189]

You seem to think that a diagnosis has to be the ultimate, final, significant factor which is ultimately responsible for the disease, injury or illness. That is not the case.

I can take one scenario of an MVC and give several examples of correct diagnosis.

-EMT arrives and diagnoses bilateral femur Fractures

-Medic arrives and diagnosis hypoperfusion-Hypovolemia (starts fluids)

-ED Doc does CTs and finds multiple fractures

-Later Blood tests reveal Bone cancer (contributing factor to the multiple fractures)

These are all correct levels of diagnosis, although clearly at different levels

 

[CAOX3]

I recognise a problem then if possible I treat the symptoms associated with the underlying problem.

If thats diagnosing then so be it, I dont get overly concerned with the definition.

 

[Veneficus]

So a sign and a symptom is essentially a diagnosis?

How many causes of CHF? Is it a sign, symptom or a disease or all?.

It is a common pathology from a number of potential causes. Here is a quick quote from Robins and Cotran Pathological Basis of Disease. (7th edtion) page 560.

"CHF is the leading discharge diagnosis in hospitalized patients over the age of 65 and has an associated annual cost of $18 billion"

So it is a diagnosis. So says what amounts to the bible of pathology.

I think you are getting too hung up on all the preceding causes of diseases. There are multiple diagnosable diseases from preceding pathologies and some that don't, like primary hypertension.

Figuring out if hypertension is primary or secondary and if so from what is why IM folks get paid what they do. Some pathologies can only be confirmed post mortem. Does that mean nobody ever made a dx?

There really is no need to make this more complicated than it is. Today I diagnosed a patient with pneumonia. Bronchial pneumonia? Lobar Pneumonia? I “guess “it was bronchial. I don't know. I don't care. When I see the culture results in a couple of days, I may suggest changing the antibiotic. (if it hasn't already been done prior to me seeing the patient, even then it might not be required.) Is it secondary to an upper respiratory infection? Most likely by both the numbers and in this particular patient. But that is simply a “guess”. An "assumption" if you will. On the official chart the Dx is still pneumonia. It will not change from that. Maybe a secondary Dx. of thrush in a day or two after antibiotics. It will not be cultured to find out if it is truly candida albicans or not. It will be assumed. No need to pay the money for the test or bother the microbiologist.

Does the patient have other pathologies that predispose to pneumonia? Sure he does. So what? His current therapy for that is being maintained. When he comes back for something else, his chief complaint will be diagnosed and it will not be a major production to find every possible pathology and benign condition once the complaint is addressed. We didn't biopsy the mass on his mandible he said had been there for 40 years and was previously diagnosed as benign. It was listed as history in his chart, physically examined and determined to meet all the requirements not to biopsy it from palpation and visualization.

Can you make the diagnosis of acute renal failure as the cause or diagnosis?

Depends on the patient.

What about wheezing? COPD or Asthma? What about all the other causes or disease processes? Do you treat the signs and symptoms or do you immediately go straight with asthma? What if it is an aspirated object? Does that change the diagnosis of the wheezing?

Unlike CHF and pneumonia, wheezing is not a diagnosable pathology. As you pointed out, that is a symptom of an underlying pathology.

How much is "assumption"?

A lot more than you seem willing to admit I'd wager.

Look in the scenarios heading for examples of the "guessing game" where some assume but really don't have much data to go on.

Nobody on any EMS site I have ever seen ever puts up enough information to make a reasonable educated guess. Look at the publication like NEJM for case presentations. PPTs of radiographs, lab values, complete history and physical findings. It just doesn't compare. The last scenario I commented on here didn't even have a full set of vitals. The history was incomplete and looked unreliable anyway. You could guess at it all day and still be no nearer the answer.

What about the commonly made diagnosis of "hyperventilation"? Isn't it really a symptom called tachypnea since there is not clinical data to prove hyperventilation?

Never saw that as a Dx. seen it as a finding though.

What if you do a glucose check on a trauma patient and find a higher BGL? Are you going to assume the patient is a diabetic?

Depends on just how high that number is. But if it is high enough the Dx will be assumed and treated in an unconscious person until something more definitive is discovered. If they are awake and alert, they will be asked. I am sure you are aware there is a body of research for aggressive glucose control in ICU.

For the fx, if you have diagnosed it, why O2? Aren't you just following your protocols instead of actually clinical findings of hypoxia? Are you also going to stop your assessment since it is so "obvious"? Any chance of emboli?

So the EMT is following treatment protocols prescribed to the patient by a physician until a higher level of provider can alter that decision. What has that got to do with Dx? You and I are held to the same requirements. We just have more leeway on what those requirements are. Are you now complaining that an EMT-B isn't allowed to make treatment decisions based on the education level? Yes there is a chance of an emboli, so what? What is the EMT in the field going to do for it? In an open Fx. there is also wound contamination, nothing to do about that in the field except rinse the superficial wound. Unless you are advocating an orthopedic surgery procedure. Even the Emergency doc is going to have to turf that one.

And, for the respiratory distress, are you going to stop your assessment after giving the SQ? Since the child was eating, is aspiration and obstruction also not a possibility as well? Rarely are things always as easy as they seem and to ASSUME one thing you may miss another.

I'm not, and the pt. is going to get some Maalox too in addition to the other tricks up my sleeve like a CXR. But the epi will come long before such bells and whistles in a patient in a medical emergent state. (Where advanced diagnostics become secondary to focused interventions.)

Yes, you must work under a preliminary diagnosis to initiate your protocols but one should also not stop assessing or believe that one diagnosis is the end all to every problem.

I don't see where he was making that assumption; merely pointing out easily diagnosed pathologies. Medicine does not always have to be some infinitely complex problem. Actually it is rather nice when it is a simple case.

Let's do another scenario since pericarditis was just mentioned in anther thread. How about the "typical" OD patient with a history of IVDA. The narcan barely touches him. Do you suspect endocardititis which can lead to a CVA and/or MI? Or do you stick with the obvious of OD and keep giving narcan to the limit allowed by your protocol? Can an unconscious patient tell you about chest pain or slurred speech? So no, not everything will be a simple textbook diagnosis and treatment symptoms or signs as you find them will be all you can do. Just assuming you made "a diagnosis" and running with that may not provide all the treatment that can be done.

I want to play too, maybe in the poorly described scenario she was using contraception, smokes and she had a PE? I am sure you have had patients who denied taking meds and then admitted to oral contraceptives when further pressed. How about endocarditis that leads to a ruptured or otherwise incompetent valve? That was an unfair challenge. Is he again supposed to take it upon himself to change the treatment modality based on pathology possibly beyond his knowledge or capability on a single patient? If that were the case, the AHA is going to have to start printing some really thick books with every possible caveat accounted for in the ACLS algorithms.

If you have ever shadowed the ED physician, you will find they may list as many as 6 or more differential diagnoses even with something that seems really obvious and will continue to treat the signs and symptoms as they appear until some definitive data is available..

And sometimes that's all they do and punt to a specialist. But there is usually only one admitting dx. "Closed head injury" being my favorite too see on a chart coming from the ED. "I have no idea" isn't really billable.

This is to get some to thing there is more than just the obvious and rarely will a patient have just one diagnosis but can have many signs and symptoms that can pertain to many disease processes each with a different definitive treatment but similar treatment of the signs and symptoms.

Isn't everyone aware of that? ACS is a common one. STEMI anyone?

http://www.ncbi.nlm.nih.gov/pubmed/19166679
For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training. A post graduate healthcare provider belittling an EMT or even a medic seems like an 40 year old finding satisfaction beating up a 3 year old for showing off their ice cream cone when the adult didn’t have one.

 

[46Young]

So a sign and a symptom is essentially a diagnosis?



It is a common pathology from a number of potential causes. Here is a quick quote from Robins and Cotran Pathological Basis of Disease. (7th edtion) page 560.

"CHF is the leading discharge diagnosis in hospitalized patients over the age of 65 and has an associated annual cost of $18 billion"

So it is a diagnosis. So says what amounts to the bible of pathology.

I think you are getting too hung up on all the preceding causes of diseases. There are multiple diagnosable diseases from preceding pathologies and some that don't, like primary hypertension.

Figuring out if hypertension is primary or secondary and if so from what is why IM folks get paid what they do. Some pathologies can only be confirmed post mortem. Does that mean nobody ever made a dx?

There really is no need to make this more complicated than it is. Today I diagnosed a patient with pneumonia. Bronchial pneumonia? Lobar Pneumonia? I “guess “it was bronchial. I don't know. I don't care. When I see the culture results in a couple of days, I may suggest changing the antibiotic. (if it hasn't already been done prior to me seeing the patient, even then it might not be required.) Is it secondary to an upper respiratory infection? Most likely by both the numbers and in this particular patient. But that is simply a “guess”. An "assumption" if you will. On the official chart the Dx is still pneumonia. It will not change from that. Maybe a secondary Dx. of thrush in a day or two after antibiotics. It will not be cultured to find out if it is truly candida albicans or not. It will be assumed. No need to pay the money for the test or bother the microbiologist.

Does the patient have other pathologies that predispose to pneumonia? Sure he does. So what? His current therapy for that is being maintained. When he comes back for something else, his chief complaint will be diagnosed and it will not be a major production to find every possible pathology and benign condition once the complaint is addressed. We didn't biopsy the mass on his mandible he said had been there for 40 years and was previously diagnosed as benign. It was listed as history in his chart, physically examined and determined to meet all the requirements not to biopsy it from palpation and visualization.



Depends on the patient.



Unlike CHF and pneumonia, wheezing is not a diagnosable pathology. As you pointed out, that is a symptom of an underlying pathology.



A lot more than you seem willing to admit I'd wager.



Nobody on any EMS site I have ever seen ever puts up enough information to make a reasonable educated guess. Look at the publication like NEJM for case presentations. PPTs of radiographs, lab values, complete history and physical findings. It just doesn't compare. The last scenario I commented on here didn't even have a full set of vitals. The history was incomplete and looked unreliable anyway. You could guess at it all day and still be no nearer the answer.



Never saw that as a Dx. seen it as a finding though.



Depends on just how high that number is. But if it is high enough the Dx will be assumed and treated in an unconscious person until something more definitive is discovered. If they are awake and alert, they will be asked. I am sure you are aware there is a body of research for aggressive glucose control in ICU.



So the EMT is following treatment protocols prescribed to the patient by a physician until a higher level of provider can alter that decision. What has that got to do with Dx? You and I are held to the same requirements. We just have more leeway on what those requirements are. Are you now complaining that an EMT-B isn't allowed to make treatment decisions based on the education level? Yes there is a chance of an emboli, so what? What is the EMT in the field going to do for it? In an open Fx. there is also wound contamination, nothing to do about that in the field except rinse the superficial wound. Unless you are advocating an orthopedic surgery procedure. Even the Emergency doc is going to have to turf that one.



I'm not, and the pt. is going to get some Maalox too in addition to the other tricks up my sleeve like a CXR. But the epi will come long before such bells and whistles in a patient in a medical emergent state. (Where advanced diagnostics become secondary to focused interventions.)



I don't see where he was making that assumption; merely pointing out easily diagnosed pathologies. Medicine does not always have to be some infinitely complex problem. Actually it is rather nice when it is a simple case.



I want to play too, maybe in the poorly described scenario she was using contraception, smokes and she had a PE? I am sure you have had patients who denied taking meds and then admitted to oral contraceptives when further pressed. How about endocarditis that leads to a ruptured or otherwise incompetent valve? That was an unfair challenge. Is he again supposed to take it upon himself to change the treatment modality based on pathology possibly beyond his knowledge or capability on a single patient? If that were the case, the AHA is going to have to start printing some really thick books with every possible caveat accounted for in the ACLS algorithms.



And sometimes that's all they do and punt to a specialist. But there is usually only one admitting dx. "Closed head injury" being my favorite too see on a chart coming from the ED. "I have no idea" isn't really billable.



Isn't everyone aware of that? ACS is a common one. STEMI anyone?

http://www.ncbi.nlm.nih.gov/pubmed/19166679
For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training. A post graduate healthcare provider belittling an EMT or even a medic seems like an 40 year old finding satisfaction beating up a 3 year old for showing off their ice cream cone when the adult didn’t have one.

I almost aspirated my dinner after reading the last part :lol:

 

[Veneficus]

I almost aspirated my dinner after reading the last part :lol:

careful now, who the hell could possibly dx that B)

 

[46Young]

careful now, who the hell could possibly dx that B)

Just use the cookbook. Can't go wrong with that

 

[VentMedic]

I almost aspirated my dinner after reading the last part :lol:

That wasn't part of my quote. That was Veneficus. But then he believes there is not need to look for a cause to the CHF as it is an end all diagnosis. That however is also how some look at a "diagnosis" as well and go with what fits to initiate a protocol.

Look at the examples we have had in the scenarios and in the news. If it doesn't "fit" one of the working diagnoses listed in someone's protocols, too bad. Look at the example of the high school football player that died. Too often Paramedics try to fit the patient into a "work diagnosis" rather than allowing the symptoms to lead them to other possibilities. How many here feel they MUST make a diagnosis to run a specific protocol? Or, if it doesn't fit, it is "BLS'd" in with or without a Paramedic even if the patient is truly sick.

Just use the cookbook. Can't go wrong with that

Thank you. That is exactly my point. As long as you can get a couple of symptoms to fit to run a protocol, it all good...except for the patients that didn't get the proper treatment because they were "fitted" into one recipe.

Originally Posted by VentMedic
How much is "assumption"?

A lot more than you seem willing to admit I'd wager.

I asked the question "how much is assumption" since I do know a large part is based on it. Much becomes a guessing game as evidenced on scenario threads as some state "looks like something I saw once" or "I heard that maybe this" rather then knowing how to actually make the diagnosis of that disease.

For some reason I just don’t feel the need to constantly point out what basic healthcare providers can’t possibly know after their few hours of training.

As far as the EMT vs Paramedic comment, the last time I looked there is a difference in the levels. But yet some do believe they are at the same level or better than any doctor. It is those I would caution to know their limitations and continue assessing since what you think you "see" may have much more to the story and may not be just "BLS".

Both of you are missing the message in my posts since I stated the use of preliminary or working diagnosis when referring to the Paramedic many times. My point is not to confuse a symptom as an end all diagnosis as there may be many other symptoms or "working diagnoses" that could be made or found.

 

[ivanh3]

I think EMTs/medics diagnose accurately quite frequently. However, some times we just address our symptoms and do follow up later. This is all part of the growth that happens during a career. I think some people get a bit caught in the cookie cutter vs critical thinking aspect of the job. There can be both. Algorithms can be great in the beginning and when there is a need for speed. Likewise with critical thinking. One is not mutually exclusive of the other.